Case Management Clinical Executive

SKILLS AND COMPETENCIES

• Excellent communication and negotiation skills
  
• Excellent public relations and interpersonal relationship skills
  
• Extensive networking with SP and other medical insurers
  
• Excellent analytical and monitoring skills
  
• Good IT skills in database management and office systems
  
• Good decision making in benefit utilization management
  
• High levels of integrity and honesty
  

3. QUALIFICATIONS, KNOWLEDGE & EXPERIENCE

• Diploma or Degree in Nursing
  
• Diploma in Insurance/ COP
  
• Degree in Health systems Management/ Business management
  
• 3 years’ experience in clinical setting +2 years in insurance set up
  

• Pre-authorize scheduled and non-scheduled admissions within the set guidelines
  
• Negotiate/discuss professional fees as appropriate for each admission
  
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration)
  
• Visit all admitted clients within Nairobi region and its environ
  
• Liaise with Doctors on the day-to-day management of patients and obtain medical reports/ expected length of stay where indicated
  
• Ensure smooth discharge process and co-ordinate any necessary post-hospitalization/ step down facility care
  
• Revise reserves after discharge of member
  
• Collect feedback from admitted clients on quality and scope of service by the service provider
  
• Assist in carrying out verification and medical audit of claims/invoices before settlement
  
• Develop and maintain monthly database on admissions, large claims and extended length of stay.
  
• Respond to queries from clients, intermediaries and service providers
  
• Liaise with other medical underwriter for purposes of market surveys and development of new controls, standards and products
  
• Any other duty assigned by management